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I. SAN JO }-,N COUNTY PUBLIC HEALTH SERVICE S/ENVIRONMEN' ,4iALTH DIVISION <br /> UGST WORKSHEET FOR SITE CLOSURE EVALUAT <br /> AME Of fACILiTY �Lp �/e e V-R 1/i i WEEPS CODE <br /> DRESS a T 1? �•s v �/� <br /> ANK 512E —" <br /> s- d UEL TYPE &VSf ! <br /> II. GENERAL SITE HISTORY <br /> Is permit current? es o ermi t <br /> acility Status Code 0� oc.Soit/GW Cont es o <br /> umber of Tanks at facility ge of Tanks(if <br /> I1J. TANK HISTORY arailab(e) <br /> ype of Tank teal Fbrg[ ngi Dual <br /> " - <br /> as Tank tested? es o ailed precision test ? es1. o 1f es J <br /> Y , give dates) / / / ! j <br /> Jas a repair made to the tank system? as No f yes, what was r <br /> epaired? <br /> as repair done under inspection? as 40 ere soil samples analyxed7es q TXE PH-G PH-D b/EDB <br /> ype of failure/discharge atastrophic long-term leakage verfiil nown cher: <br /> IV. REMOVAL HISTORY (ATTACH INSP CTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received es p <br /> m"P ✓ a e th to Ground Warer cf/Year -erase Annual Precipitation <br /> -Site Wells) es o ! <br /> umber & Type Irr am ub <br /> S Score S Score S core <br /> istance to 41e1i(s) from Tank ft• IM i <br /> ft; it C 0 pts C. 4 pts C pts i <br /> 0 if 0 if 0 f <br /> W. Rondition R condition R �ondition <br /> Site Feature - leaching Potential Analysis E is met E is met E is met <br /> inimum Depth to groundwater from the Soil Swrpte (feet) 31 k ),10051-100 25-50L <br /> ' t <br /> ractures in subsurface (applies to foothills or mountain areas) None Unknown resent <br /> verage Annual Precipitation (inches) i <br /> xxix 00 9 10-25 KXXXXXA 26-4012 <br /> an-Made conduits which increase vertical migration E <br /> Df leachate ,(i.e., septic systems, water Neils, ponds) None Unknown resent <br /> pique site features: Recharge area, coarse soil, nearby wells. i At least lore than <br /> xxzx None one one <br /> Ey <br /> COLUMN TOTALS),»TOTAL POINTS f( + <br /> 3Z <br /> Sample <br /> e Rfesult: (B T X OR E) RANGE OF TOTAL POINTS 9 pis or more Q� 41 - 48 pts 40 pts or less <br /> I{J <br /> r D BT'. X E B 7 X E � <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50. 3 .3 1. 1. NAL <br /> Sample Result: FIESOEL <br /> NE ;1000 100 10 + <br /> TPH IMUM ALLOWABLE TPH LEVELS (PPM) ! <br /> 10,000 1000 100 <br /> FOOTNOTES: '"•If documented soil and/or ground water contamination is'present, do not complete the teaching potential <br /> analysis. (i.e., site is currently an UGT Contamination List for soil or ground water.) <br /> -L1 If depth is ), 5 ft. and < 25 ft., score 0 points. If depth -5 ft., do not use tabte. <br /> L If precipitation is > 40 inches, score 0 points. it <br /> L Levels for BTX&E are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> VI. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX & E or TPH Concentrations > Allowable Levels Yes oFV <br /> f <br /> 2. Recommend Site Closure es a 1 If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A SUPERVISOR/SENIOR + <br /> ;1 <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE fES 0 EFERRED TO SITE MITIGATION FOR EVALUATION fES q k <br /> ATE REFERRED / / ATE CLOSURE LETTER MAILED <br /> AME OF <br /> =VALUATOR s� <br /> EH 23 80 (UGTWKSHT)\5/90 I <br /> J <br /> I <br />